Chronic pancreatitis (CP) is a debilitating disease with pancreatic inflammation and fibrosis leading to endocrine and exocrine insufficiency, which can cause malnutrition and diabetes. Pain is the main symptom, and all types of treatment aim at reducing it. First line of treatment include analgesics, oral replacement therapy with pancreatic enzymes, alcohol abstinence, and endoscopic manoeuvres (celiac plexus blockade, dilation and stent placement). When medical treatment fails (or malignancy is suspected), surgery becomes an option. Two groups of procedures exist:
Drainage procedures
Puestow procedure (longitudinal pancreaticojejunostomy)
Frey's procedure (pancreatic head "shell-out" plus longitudinal pancreaticojejunostomy)
Resection procedures
pancreaticoduodenectomy (Whipple)
distal pancreatectomy
total pancreatectomy
95% distal pancreatectomy
duodenum-preserving resection of pancreatic head (Beber procedure)
The choice of a drainage procedure over a resection one, depends not on the aetiology but on the presence of pancreatic duct obstruction and dilation (>7 mm). If a normal duct is found, the local of pancreatic inflammation and the presence of duodenum stenosis will help decide which resection should be performed. If a malignancy/inflammatory mass is suspected resection is the correct option. In resume, surgery aims at pancreatic duct drainage and/or resection of diseased pancreas.
Although all these procedures try to reduce pain and many papers evaluate only this primary outcome, there is a lack of studies evaluating nutritional status after surgery. Will surgery increase nutritional status? Lets see...
In Japan, Frey's procedure (FP) is the standard procedure for CP since 1990. The Department of Surgery from Tohoku University in Sendai, Japan, is the leading department in CP treatment, having the greatest experience performing Frey's procedure in whole Japan. Hideaki Sato et al retrospectively analysed the nutritional status, before and 1 year after surgery, of all patients submitted to Frey's procedure or pancreaticoduodenectomy (PD) for CP between 2005 and 2014 in that department.
They used the CONUT score which is a tool that uses three laboratory tests to analyse the nutritional status: serum albumin; lymphocyte count, total cholesterol. It gives four grades: 0-1 pts normal nutrition; 2-4 pts mild malnutrition; 5-8 pts moderate malnutrition; 9-12 pts severe malnutrition.
The authors analysed 42 patients from a total of 61 (19 were lost at follow-up). Thirty five (35) were submitted to FP and seven (7) to PD. Median duration from CP to surgery was 5y in FP group, and 0,58y in the PD group. In FP group CP was acohol-related in 30, idiopathic in 5 and hereditary in 1. In the PD group causes of CP were alcohol in 5, malfunction of pancreaticobiliary duct in 1, and autoimmune in 1.
Alcohol was the main cause of chronic pancreatitis in Frey's procedure group as well as in pancreaticoduodenectomy group.
All patients were pain-free and on oral pancreatic enzymes at discharge date. There were better perioperative outcomes for Frey's procedure (less operative time, less blood loss), but there were no differences in morbidity nor mortality. Hiedaki Sato et al report a reduction in mean CONUT score for Frey's procedure: before surgery = 4; 1 year after surgery = 1 (p<0,0001). After FP there wasn't any case of moderate nor severe malnutrition comparing with the 8 and 2 cases before surgery, respectively. In contrast, the authors report the same mean CONUT score before and 1y after PD: 2 (p=0,9).
"...the nutritional status after Frey's procedure was significantly better than after pancreaticoduodenectomy ".
Hiedaki Sato el al
Additionally the authors studied the 28 patients that were on pancreatic enzymes before and after surgery, trying to take conclusions on the effects of the FP itself. Results were evident. There was a significant decrease in pain (p<0,01) and a significant decrease in CONUT score (p<0,01).
These data support the therapeutic effect of FP on both pain and nutritional status of patients with CP.
Hiedaki Sato suggest three mechanisms that can justify these results. First, pain relief may allow for oral intake resumption. Second, exocrine function improving after chronic inflammation reduction and pancreatic duct clearing. Third, the technique preserves pancreatic parenchyma with minimal resection of pancreatic head, keeping the potential source of pancreatic juice and insulin.
As a final comment about this paper, there is a major drawback, I think. The authors put into the same equation all the patients with chronic pancreatitis, meaning that patients with or without pancreatic duct dilation are analysed together. Will a drainage procedure have benefits in a chronic pancreatitis with a non-dilated pancreatic duct? Will a resection procedure be a good option in the presence of a pancreatic duct obstruction/dilation? This is not assessed throughout the entire study. Hiedaki Sato et al do not explain how was the decision making process for choosing surgical procedure.
Nevertheless, it is an interesting study, using a simple and easy tool to analyse the nutritional status of all surgical patients. I believe CONUT score can be of good help in daily surgical practice.
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon